Back to Pruning the Roses
Mrs. Gunder was my last scheduled patient of the morning. I blessed my staff, who knew her well enough to schedule her appointment at the end rather than the beginning of the morning. This dear woman is one of several patients who often need more time with me than they requested when making their appointment.
Walking down the hall to the exam room, she leaned forward a bit more on her walker and moved a bit more slowly than usual. I popped into my office while the medical assistant took her blood pressure and checked her list of medications against the bottles Mrs. Gunder had brought. I heard the usual laughing and teasing comments while I rummaged for the article I wanted to show this patient.
In short order, seated next to her, I could tell Mrs. Gunder was in pain-despite her attemps to downplay any complaints. "So, tell me what's up and how you think we can help you today..." I asked her.
"Well, first let me tell you that I'm not planning to let you tell me I have to move to some assisted living place and out of my own home. That said, I have been hard pressed to manage my usual housekeeping because my back has become very painful. Even getting to the kitchen is a trial. I can no longer reach to the shelf with my teacups because of this sharp pain in my back, and I hate drinking tea from a coffee mug! I thought this weekly bone medicine I'm taking was suppose to keep me from having more spine fractures. The pain feels just like when I had that spine fracture last year. That took months to heal and for the pain to quit. I tell you, I'm disgusted with all this..."
I decided that I would hold my tongue a bit with my next question and instead simply sat quietly for what seemed like an eternity until Mrs. Gunder added, "I need to know why I have this osteoporosis and why you can't give me something to really make it better. I do take my weekly pill just like you said to and try to walk as much as I can about the house and in my garden. I even take the calcium tablets regularly. And, oh yes, I do worry that these pain meds dope me up so much that I'll get addicted."
As I listened to Mrs. Gunder, I tried to understand her concerns within the full context of her living situation and plan accordingly. She lives alone and has maintained her home and garden on her own since widowed 10 years ago. Lately, she goes out less and is more isolated.
Her local circle of friends is limited. She'll again need Home Health care services, as with her previous spinal fracture, to get her through this setback. She managed through that episode with pain medications, but the appearance of this fracture on X-ray is worse.
Knowing she needs to understand in order to accept procedures and tratments, I began to explain as much to her as I thought would help at this point. I pulled up Google Images on my laptop screen to show her pictures of healthy and osteoporotic bones-as well as a fracture comparable to hers.
"Studies show that patients' pain diminishes sooner after having vertebroplasty procedure (relatively new high tech procedure that uses a balloon and cement to restore the vertebral height)." I found a Web site that showed this to her visually. She agreed to be referred for the vertebroplasty. But that did not fully address her issue of fracture recurrence.
Michael Holick, PhD, MD, in his presentation on "The Vitamin and Calcium Crisis: Strategies to Improve Bone Health" emphasized that Vitamin D deficiency is an unrecognized epidemic in adults 50+ years and is a key factor in bone loss. Less dietary calcium is absorbed when Vitamin D is deficient and much higher doses than currently recommended are needed to maintain healthy levels.
Sun exposure also allows our skin to manufacture Viamin D.
Insufficient Vitamin D can cause osteomalacia (altered bone formation which can cause generalized or isolated bone pain, unlike osteoporosis which does not hurt unless the bone fractured). Higher 25-hydroxyvitamin D concentrations are associated with better lower-extremity function in both active and inactive persons aged over 60 years.
Mrs. Gunder's 25-hydroxyvitamin D was 19ng/ml (optimally>30ng/ml). I had recently prescribed 1000 IU daily, but, per Dr. Horlick, I advised 50,000 IU a week for eight weeks and then every other week for maintenance. Vitamin D usually comes in 400-1000 IU size, so I researched my Nutraceutical sources (I make it a priority to know which nutritional supplemement manufacturers have rigorous quality control for their manufacturing processes) and found one that makes a 50,000 IU capsule of Vitamin D.
I'm happy to report that after several months, Mrs. Gunder is out in her garden, pruning her roses.
By Dr. Winni Loesch
Article published in The Union, Nevada County Newspaper on June 1, 2007.